Pancreatic damage

Introduction to pancreatic injury The pancreas is a retroperitoneal organ with a deep position and is attached to the posterior peritoneum of the upper abdomen. Because of its anatomical features, it is well protected. Only when external factors directly affect the pancreas, or blunt violence directly acts on the upper pancreas. The abdomen can damage the pancreas. Pancreatic injuries are often associated with damage to adjacent organs such as the duodenum, biliary tract, stomach, colon, spleen, kidney, and adjacent large blood vessels. basic knowledge The proportion of illness: the probability of directly causing the disease in traumatic diseases is about 0.02%-0.04%, more common in abdominal trauma Susceptible people: no special people Mode of infection: non-infectious Complications: pancreatic fistula, abdominal abscess, abdominal pain, paralytic ileus, pancreatic pseudocyst, bloating

Causes of pancreatic injury

Closed injury (45%):

The position of the pancreas is relatively fixed, and then it is close to the hard vertebral body. Therefore, when blunt violence directly affects the upper abdomen, the pancreas is easily crushed or broken due to being squeezed. For example, the patient is unprepared in the event of a car accident. In the case, the steering wheel or the armrest squeezes the upper abdomen, and when the height falls, the upper abdomen hits the crossbar.

Open injury (35%):

(1) Cut injury: sharp instruments such as knives directly cut the pancreas, often accompanied by other abdominal internal organs such as liver, stomach, duodenum damage.

(2) Gunshot wounds: more common in wartime, bullets in the upper abdomen or waist, shells shrapnel, injury to the pancreas, bursting of bullets or multiple shrapnel can cause laceration of pancreatic tissue, complicated treatment, poor prognosis .

(3) iatrogenic injury: less common, some abdominal organ surgery such as stomach, duodenum, spleen and colon surgery, can damage the pancreatic tissue.

Pathogenesis

Degree of damage

According to the pathological degree of pancreatic injury, it can be divided into mild contusion, severe contusion and partial or complete fracture injury. The pathological degree of pancreatic injury is the basic basis for the pathological classification of pancreatic trauma.

(1) mild contusion: only caused pancreatic tissue edema and a small amount of bleeding, or formation of small hematoma under the pancreatic capsule, sometimes a small amount of pancreatic acinar and small pancreatic duct may also be destroyed, resulting in a small amount of pancreatic juice spillover and mild pancreas Tissue self-digestion, clinical manifestations of traumatic pancreatitis, pancreatic superficial laceration without large pancreatic duct injury should be classified as mild contusion, this injury generally does not cause serious consequences, and more can heal itself.

(2) severe contusion: severe pancreatic contusion, partial pancreatic tissue necrosis loses vitality, and there is a large or relatively thick pancreatic duct rupture resulting in a large amount of pancreatic juice spillover, after the digestive enzyme in the overflow pancreatic juice is activated, Pancreatic tissue itself digests, causing more necrosis of the pancreatic tissue and corrosion of the surrounding tissues of the pancreas, saponification, etc. If the digestive enzymes rupture the large blood vessels in the pancreas, it may cause severe internal bleeding. If the pancreatic juice overflows slowly, it is surrounded by Wrapped in tissue, can form pancreatic pseudocyst, relatively large pancreatic laceration or deep pancreatic laceration (such as knife stab wound) that may be associated with large pancreatic duct injury, although there is no extensive and severe pancreatic tissue local contusion , necrosis, should also be attributed to severe contusion.

(3) A laceration less than 1/3 of the circumference of the pancreas: due to a severe contusion, a laceration that exceeds 1/3 of the circumference of the pancreas is attributed to a partial fracture, and a laceration that exceeds 2/3 of the circumference of the pancreas is attributed to a complete fracture. The site of the fracture is usually located in front of the spine, the left side of the blood vessel on the mesentery, that is, the pancreatic neck or the proximal side of the pancreatic body, sometimes at the junction of the pancreatic body and the tail, and some of the fractured parts may be on the dorsal or ventral side of the pancreas. When the dorsal side of the pancreas is not easy to be found during surgery, the pancreatic tissue close to the plane of the fracture may be contused, and the necrosis is not very serious. It may also be a serious fracture of the section. The main problem of this pancreatic injury is the involvement of the large pancreatic duct. (main pancreatic duct or larger accessory pancreatic duct), causing partial or complete rupture, resulting in a large amount of pancreatic juice spilling out. The closer the pancreatic duct rupture site is to the pancreatic head side, the more pancreatic fluid overflows, resulting in secondary self-organizational digestion and The infection is also more serious.

2. Damage site

The same pathological degree of pancreatic injury occurs in different parts of the pancreas. The degree of threat to life, the incidence of comorbidities and the prognosis are different. Therefore, the severity of the complication is different. The surgical procedure is different, such as only the tail of the pancreas. Severe laceration, simple pancreatic tail resection, the prognosis is good, but the severe contusion of the head of the pancreas, the treatment is more complicated, according to the location of pancreatic injury can be divided into pancreatic head injury, pancreatic neck Body damage and pancreatic tail injury.

3. Whether combined with duodenal injury

According to whether combined with duodenal injury, it can be divided into simple pancreatic injury and pancreaticoduodenal combined injury. Pancreatic duodenal combined injury is caused by direct injury to the right upper abdomen, often involving the head of the pancreas and the twelve fingers. The intestine is a serious condition in the pancreatic injury. After the injury, the pancreatic juice, duodenal juice and bile are mixed, and a large amount of spilled into the abdominal cavity. The pancreatic enzyme is activated rapidly, and the surrounding tissue has a strong digestion effect, and the mortality rate is high. .

The above three factors can be randomly combined to represent a complex type.

At present, there is no unified classification standard for pancreatic trauma at home and abroad. The following several types of classification systems can be found in the literature.

Lucas divides pancreatic trauma into 4 types:

1 mild contusion or laceration, no major pancreatic duct injury;

2 The contusion or rupture of the distal part of the pancreas is suspected of large pancreatic duct injury, or the contusion of the proximal part of the pancreas, that is, the pancreatic head, without large pancreatic duct injury;

3 the proximal part of the pancreas, that is, the contusion or fracture of the head of the pancreas, suspected or large pancreatic duct injury;

4 severe pancreatic and duodenal injuries.

Smego believes that the presence or absence of pancreatic duct injury is the key to the success of treatment. The proposed pancreatic trauma classification is:

1 pancreatic contusion or subdural hematoma;

2 pancreatic parenchymal hematoma without large pancreatic duct injury;

3 pancreatic mass break, there may be large pancreatic duct damage;

4 severe contusion and laceration.

The classification proposed by Japans Zhenrongcheng:

1 mild contusion;

2 laceration;

3 severe contusions;

4 transverse injury.

Domestic Anton's classification: I degree: mild contusion of the pancreas, including subcapsular hematoma, small parenchyma of the pancreatic parenchyma, no main pancreatic duct injury; II degree: severe contusion of the pancreas, including Deep pancreatic parenchyma or large area shallow laceration and suspected main pancreatic duct injury; III degree: main pancreatic duct injury; IV degree: pancreatic head duodenal combined injury.

Pancreatic injury prevention

Since the disease is caused by trauma, there are currently no preventive measures. Usually pay attention to prevent trauma.

Pancreatic injury complications Complications pancreatic fistula abdominal abscess abdominal pain paralytic ileus pancreatic pseudocyst bloating

The incidence of complications after pancreatic injury is high, ranging from 20% to 40%. Complications occur mainly with the location, extent, clinical pathology, and shock of the pancreatic injury. , surgical methods, the surgeon's clinical experience and skills, the main complications are:

1. Pancreatic fistula: is the most common complication after pancreatic injury, also known as pancreatic fistula or pancreatic skin sputum. Pancreatic head injury occurs more often than pancreatic body and tail injury. The tube is thicker, the pancreatic juice drainage in the pancreatic duct is large and the operation of the pancreatic head injury is not easy to be completely related. The pancreatic fistula is more common after normal pancreatic injury, and the pancreatic fistula is more common in patients with chronic pancreatitis or pancreatic fibrosis. less.

2. Abdominal abscess: The incidence of abdominal abscess is about 25%. It is related to the extent and extent of pancreatic injury, combined with gastrointestinal damage, poor abdominal drainage and pancreatic fistula.

3. Intra-abdominal hemorrhage: most of the recent bleeding comes from pancreatic wounds. The late hemorrhage is caused by the rupture of the pancreatic juice in the abdominal cavity. Occasionally, continuous intra-abdominal hemorrhage occurs during pancreatic fistula and intra-abdominal infection. This is difficult to deal with. The case fatality rate is extremely high.

4. Traumatic pancreatitis: In patients with pancreatic injury, upper abdominal pain, with signs of paralytic ileus, serum amylase concentration increased, should consider traumatic pancreatitis.

5. Pancreatic pseudocyst: The incidence rate is 20%, mostly due to no pancreatic duct injury found in the operation or pancreatic parenchyma accumulated in the pancreatic parenchyma without adequate drainage.

6. Pancreatic insufficiency: pancreatic insufficiency can occur due to severe pancreatic injury or excessive resection. Exocrine deficiency is mainly manifested as abdominal distension and steatorrhea; endocrine deficiency is characterized by hyperglycemia and high urine sugar.

Symptoms of Pancreatic Injury Common Symptoms Intestinal Pain Abdominal Pain Low Heat Nausea Abdominal Discomfort Blood Pressure Drops Reversal Abdominal Pain Bloating Cyst

Simple pancreatic injury is rare in clinical practice, accounting for only about 10% of cases of pancreatic injury, and most pancreatic injuries combined with other abdominal organs and other parts of the body such as head injury, chest injury or large blood vessel damage, pancreas Symptoms and signs of injury are often masked by the signs and symptoms of other organ damage, especially with head injury or large blood vessel damage, and are related to the extent of the injury and the type of pathology.

1. mild pancreatic injury

Most of the symptoms are mild, such as abdominal closed injury, local skin contusion, congestion; visible developmental injury, abdominal wounds and bleeding, patients may have mild upper abdominal discomfort, mild peritoneal irritation; or no symptoms In a few weeks, months or years after the onset of upper abdominal mass or gastrointestinal obstruction (caused by pancreatic pseudocyst), some patients with chronic pancreatitis, pancreatic fibrosis, etc., long-term upper abdominal discomfort, low fever And shoulder pain and other symptoms.

2. Severe pancreatic injury

Most of the upper abdominal pain, nausea, vomiting, hiccups, caused by pancreatic juice overflow into the abdominal cavity, part of the patient's overflow of pancreatic juice is limited to the retroperitoneal or small omental sac, there is shoulder and back pain, and abdominal pain is not obvious, pain and Internal hemorrhage can cause shock, irritability, unconsciousness, pale face, cold and cold limbs, shortness of breath, rapid pulse, decreased blood pressure, physical examination revealed abdominal distension, abdominal breathing significantly weakened or disappeared; abdominal tenderness, rebound tenderness and muscle Tension, mobile dullness is positive, bowel sounds are weakened or disappeared, and abdominal puncture is not coagulated.

3. Penetrating pancreatic injury

According to the location, direction and depth of the wound, the possibility of pancreatic injury may be inferred. The penetrating injury often combines with other organs, and the damage of the pancreas may be neglected. Therefore, if there is no large amount of blood loss in the upper abdomen, there is obvious shock. Pancreatic injuries should be considered when performing.

4. Surgery-induced pancreatic injury

Difficulties in diagnosis, due to its clinical manifestations are quite inconsistent, mostly manifested as persistent upper abdominal pain, vomiting, fever, pulse increase in the early postoperative period; abdominal tenderness, muscle tension, delayed bowel sounds can not be recovered; The wound is drained and the skin is corroded. If the level of amylase in the drainage fluid or the puncture fluid is high, the diagnosis can be determined.

Because the pancreas is located in the retroperitoneum, the position is deep and concealed, the symptoms and signs are not obvious after the injury, and the pancreatic injury is combined with the damage of other organs or tissues. In the open pancreatic trauma, the liver, stomach and large blood vessels combined injury accounted for 53 %, 50% and 42%, in the blunt pancreatic injury, liver, spleen, duodenum and large blood vessels combined injury accounted for 26%, 20%, 13% and 9%, respectively, so the early diagnosis of pancreatic injury Difficulties, for the diagnosis of pancreatic damage should pay attention to the following points:

1 For patients with abdominal injury, whether it is closed or open injury, the possibility of pancreatic injury should be considered, especially in patients with upper abdominal injury.

2 patients with upper abdominal injury, abdominal pain, nausea, vomiting; examination of peritoneal irritation, bowel sounds disappeared; test serum amylase and peritoneal puncture or lavage amylase continued to rise; imaging examination found Pancreas enlargement, deformation, uneven density, signs of fluid accumulation around the pancreas, and the possibility of diagnosis of pancreatic injury.

3 clinical pancreatic injury mostly combined with multiple organ damage in the abdominal cavity, can mask the performance of pancreatic injury; some patients with pancreatic injury, due to pancreatic juice accumulation in the retroperitoneal or omental sac, and pancreatic juice secretion in the early stage of pancreatic injury is inhibited, spilled pancreatic juice In the absence of activation of pancreatic enzymes, the early symptoms and signs are not obvious. At this time, the diagnosis of pancreatic injury should not be easily ruled out, but dynamic observation should be carried out to pay attention to the changes of symptoms and signs, the dynamic changes of serum amylase concentration and Changes in imaging findings.

4 patients with abdominal injury, if there is indication for exploratory laparotomy, laparotomy should be performed as soon as possible, the exploration should be comprehensive and detailed, in principle, the liver, spleen and other substantial liver devices should be explored first, and the diaphragm should be explored for damage; then the stomach , the first part of the duodenum, the ileum and its mesentery, pelvic organs; then the incision of the gastric ligament revealed the omental sac, the posterior wall of the stomach and the pancreas, if necessary, the incision should be performed after the peritoneal exploration In the second, third and fourth segments of the duodenum, the pancreatic head and the tail of the pancreas must be revealed when examining the pancreas for detailed examination.

Pancreatic injury examination

Laboratory inspection:

1. Blood test: red blood cell count decreased, hemoglobin and hematocrit decreased, white blood cell count increased significantly, and early white blood cell count increased due to inflammatory reaction.

2. Determination of serum amylase: There is no specific laboratory test to accurately diagnose pancreatic injury. The serum amylase of pancreatic closed injury is higher than that of penetrating, but the value of serum amylase determination in the diagnosis of pancreatic injury is still reported in the literature. It is controversial that some patients with pancreatic injury may not increase serum amylase in the early stage. At present, most of them think that serum amylase exceeds 300 Susie units, or serum amylase is continuously and dynamically measured after injury. If there is a gradual increase trend, it should be used as a diagnostic pancreas. An important basis for damage.

3. Determination of urinary amylase: urinary amylase gradually increased after 12~24h after pancreatic injury, although it was later than serum amylase, but it lasted for a long time. Therefore, urine serum amylase measurement is helpful for the diagnosis of pancreatic injury. Patients with suspected pancreatic injury have a long-term observation, and if the urinary amylase is >500 Susie units, it has certain diagnostic significance.

4. Determination of amylase in abdominal cavity puncture: in patients with early or mild pancreatic injury, abdominal puncture can be negative, patients with severe pancreatic injury, abdominal puncture fluid is bloody, amylase is elevated, can be higher than serum amylase Some people think that more than 100 Susie units can be used as a diagnostic criterion.

5. Determination of amylase in peritoneal lavage fluid: For patients with suspected pancreatic injury, abdominal symptoms and signs are not obvious, and the systemic condition is stable. If the abdominal puncture is negative, the concentration of amylase in the lavage fluid can be determined after peritoneal lavage. It has certain value in the diagnosis of pancreatic injury.

Other inspection

1. X-ray film: visible large soft tissue dense shadow on the upper abdomen, left psoas muscle and kidney shadow disappear, abdominal fat line lordosis or disappear, caused by pancreatic swelling and peripheral bleeding; if combined with gastroduodenal rupture The rib rib bubble or the free gas under the armpit can be seen.

2. B-ultrasound: can determine the damage and location of the parenchymal organs (liver, kidney, pancreas, etc.), extent, extent, and intra-abdominal localized infection, abscess, can find localized or diffuse enlargement of the pancreas, The echo is enhanced or weakened, the hematoma and pseudocyst are formed, and the diagnostic puncture can be located. The fracture injury can be seen in the linear or banded hypoechoic area of the laceration, but the test is susceptible to intestinal gas accumulation.

3. CT examination: CT is of high value for the early diagnosis of pancreatic injury, because it is not affected by flatulence, CT manifests as diffuse or limited pancreatic enlargement, non-uniformity of unclear or incompletely wrapped pancreas Fluid accumulation, CT value of 20 ~ 50Hu, pancreatic edema or peripancreatic effusion, thickening of the left anterior fascia, visible lesions on the enhanced CT showed a low density of linear or banded defects, combined with duodenal injury Parenteral gases or contrast agents can also be seen.

4. Endoscopic retrograde cholangiopancreatography (ERCP): This test sometimes has a certain diagnostic value for pancreatic injury caused by acute abdominal injury. It can be found that contrast agent spillover or pancreatic duct interruption is a reliable method for diagnosing the presence or absence of main pancreatic duct injury. However, the examination can have 4% to 7% of complications, the mortality rate is 1%, and the upper digestive tract reconstruction surgery, severe esophagogastric duodenal stricture and critically ill patients can not tolerate this examination, abdominal closure The injured patient undergoes the examination after the acute phase, and the pathological condition of the pancreatic duct can be clarified, which is of great value for the determination of the surgical plan.

5. Magnetic Resonance Cholangiopancreatography (MRCP): MRCP is a new, non-invasive technique for observing the anatomy and pathology of the pancreaticobiliary system. It can show the natural state of the pancreaticobiliary duct and tissue structure without injection of contrast agent pressure. The effect, which can complement ERCP, is one of the important diagnostic tools for biliary and pancreatic diseases.

6. Diagnostic laparoscopic exploration: The advantage of laparoscopic exploration is that it can directly observe the injured organs and determine whether there is active bleeding, which not only provides accurate diagnosis, but also facilitates the selection of appropriate treatment plans, while avoiding unnecessary laparotomy. Surgery, reducing the complications and mortality caused by surgery, can prevent 54% to 57% of patients avoid surgical exploration; but it is still an invasive diagnosis and treatment, the diagnosis of retroperitoneal organs is not as good as CT examination, intestinal Injury may be missed. There are a lot of internal bleeding and obvious peritonitis. It is very important to choose the case. It is very important to choose a case. It is reported that TV laparoscopic exploration is highly suspected and can not rule out abdominal organ injury or has confirmed abdominal cavity. Intra-organic injury, but relatively stable hemodynamics of abdominal trauma; different degrees of disturbance of consciousness caused by clinical manifestations and signs of blurred, need to rule out severe intra-abdominal organ injury; unexplained hypotension, etc., hemodynamics caused by intra-abdominal hemorrhage Very unstable, history of abdominal surgery, pregnancy, abdominal trauma with abdominal cramps is a contraindication, in the general surgery diagnostic electrical The incidence of complications of laparoscopic exploration was 0% to 3%. The main complications were perforation of hollow organs, subcutaneous emphysema, omental emphysema, and wound infection.

Diagnosis and diagnosis of pancreatic injury

diagnosis

Because the pancreas is located in the retroperitoneum, the position is deep and concealed, the symptoms and signs are not obvious after the injury, and the pancreatic injury is combined with the damage of other organs or tissues. In the open pancreatic trauma, the liver, stomach and large blood vessels combined injury accounted for 53 %, 50%, and 42%, while in blunt pancreatic injury, liver, spleen, duodenum, and large vessel combined injuries accounted for 26%, 20%, 13%, and 9%, respectively.

Therefore, the early diagnosis of pancreatic injury is difficult. For the diagnosis of pancreatic injury, the following points should be noted: 1 For patients with abdominal injury, whether it is closed or open injury, the possibility of pancreatic injury should be considered, especially Patients with abdominal injuries should think of this more. 2 patients with upper abdominal injury, abdominal pain, nausea, vomiting; physical examination of peritoneal irritation, bowel sounds disappeared; serum amylase and peritoneal puncture or lavage amylase continued to rise; imaging examination found Pancreatic enlargement, deformation, uneven density, signs of fluid accumulation around the pancreas, and the possibility of diagnosis of pancreatic injury are large. 3 clinical pancreatic injury mostly combined with multiple organ damage in the abdominal cavity, can mask the performance of pancreatic injury; some patients with pancreatic injury, due to pancreatic juice accumulation in the retroperitoneal or omental sac, and pancreatic juice secretion in the early stage of pancreatic injury is inhibited, spilled pancreatic juice In the absence of activation of pancreatic enzymes, the early symptoms and signs are not obvious. At this time, the diagnosis of pancreatic injury should not be easily ruled out, but dynamic observation should be carried out to pay attention to the changes of symptoms and signs, the dynamic changes of serum amylase concentration and Changes in imaging findings. 4 patients with abdominal injury, if there is indication for exploratory laparotomy, laparotomy should be performed as soon as possible, the exploration should be comprehensive and detailed, in principle, the liver and spleen and other substantial liver devices should be probed first, and the diaphragm should be explored for damage; , the first part of the duodenum, the jejunum and its mesentery, pelvic organs; then the gastric ligament is incision to reveal the omental sac, the posterior wall of the stomach and the pancreas are examined, and if necessary, the peritoneal exploration should be performed after incision The second, third and fourth segments of the duodenum. When examining the pancreas, the head of the pancreas and the tail of the pancreas must be revealed for detailed examination.

Differential diagnosis

The disease does not need to be differentiated from other diseases.

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